how to request excess medical benefits - Chubb Group of Insurance ...

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CHUBBPrimaryBaggage ProtectionBaggage DelayInsured’s Statement(Please print – Attach separate sheet if additional space required)INSURED INFORMATIONInsured’s Name________________________________________________________________ Soc. Sec. No. _______-_______-_______Insured’s Address______________________________________________________________ Phone No. (H)_______________________________________________________________________________________________________ Phone No. (W)_________________________Policy Number (Required)________________________CLAIM INFORMATIONDate of loss, damage or delay ______/_______/_______ Time of day _____________ a.m. p.m.Please describe in detail where and how the loss, damage or delay occurred: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe in detail the nature and extent of loss, damage or delay: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Did loss, damage or delay occur while insured property was on, or in the custody of a common carrier (e.g., railroad, airline, cruise ship,bus, taxi, etc.)? If yes, please complete the following:Name of carrier: ______________________________________Flight, trip or tour number: ______________________________Was the carrier notified at the time of the loss or damage? ____ If yes, please identify where, when and to whom (name and title) notificationwas given:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Was extra valuation on property declared? __________Was baggage checked at the time of loss or damage? _________If yes, how much? _________________________________If yes, please enclose claim checkHas formal claim been filed against the carrier? __________If yes, has payment been made to you? ________________If yes, amount received? _____________________________
CLAIM INFORMATION (Cont’d)Was loss reported to police or other authorities? _________ If yes, please identify where, when and to whom (name and title) loss wasreported: __________________________________________________________________________ Case # ____________________________Valuation of lost and / or damaged propertyDescription Date and place of purchase Original CostReplacementCost or EstimateAmountClaimed123456789(attach bills of sale, receipts or estimates)Are any claimed items used in your business, occupation or profession? ______________If yes, identify the item(s) by * above.AUTHORIZATIONI authorize any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motelor similar entity providing lodging on a rental/lease basis or any other person who may have knowledge regarding this claim to release anyinformation requested regarding this claim and the loss reported.I understand this information will be used by the Chubb Group of Insurance Companies, or its authorized representatives, for the purpose ofevaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree thata photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the durationof this claim.I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing anymaterially false, incomplete or misleading information may be subject to prosecution for insurance fraud.Signed (Insured or authorized person) _________________________________________________________________ Date ____/____/____
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